Verma: States Can Impose Medicaid Work Requirements

'Able-bodied' enrollees not intended target for Medicaid, top CMS official says

ARLINGTON, Va. -- The Centers for Medicare and Medicaid Services (CMS) will allow "community engagement" -- also known as work requirements -- in state Medicaid waiver requests, according to CMS administrator Seema Verma.

"We will approve proposals that promote community engagement activities," Verma said during a speech at the National Association of Medicaid Directors Conference on Tuesday. "For the future of our country, we need all Americans to be active participants in their communities."

She argued that the resistance to work requirements for working-age, "able-bodied" individuals, reflects the "soft bigotry of low expectations" fostered under the Obama administration. Work requirements or community engagement includes holding a job, attending job training, volunteering, or going to school.

Verma also criticized the Medicaid expansion under the Affordable Care Act (ACA), which increased eligibility to the program from 100% of the federal poverty level to 138% in states that chose to allow it, as "further exacerbating" Medicaid's problems and "jeopardizing care for our most vulnerable citizens."

And she drew a line between those "deserving Americans" and the newly enrolled expansion population. The ACA, Verma claimed, put "millions of working-age, non-disabled adults" into a program that was created to care for seniors in need, pregnant mothers, children, and people with disabilities.

The expansion stretched "the safety net for some of our most fragile populations, many of which are still on waiting lists for critical home-care services while states enroll millions of newly eligible, able-bodied adults," she stated (Verma mentioned the word "able-bodied" at least half a dozen times in her speech, and at least once during a short question-and-answer question).

Verma also revealed her new vision for Medicaid, one that involves re-imagining the federal-state partnership, which currently isn't a partnership at all, she said.

Medicaid's share of states' budgets has grown from 10% in 1985, or about $33 billion, to 29% in 2016, roughly $558 billion, sapping resources from economic development and education. As federal spending grew, federal oversight grew with it, she said.

"As we turn the page in the Medicaid program, CMS wants to support states in their efforts -- we want you to create innovative programs for the people you serve -- because we believe you know what is best," she said. To that end, Verma spoke of changes to the waiver, and state plan amendment process, that she said would help states to lower costs, improve quality, and deliver value.

She announced the following changes:

Allow waivers approvals to last for up to 10 years, if they've been proven to be successful

Verma also highlighted new guidance aimed at expanding access to substance use disorder treatment for Medicaid beneficiaries.

"We are waiving the 1970s era law that prevented Medicaid beneficiaries from receiving treatment for substance use in certain settings," Verma said, alluding to the Institutions for Mental Diseases exclusion, which previously blocked Medicaid from reimbursing for mental health and substance use facilities with more than 16 beds.

Verma also outlined efforts to improve accountability and program integrity, including the creation of a "state by state Medicaid and CHIP scorecard." Scorecards would be used to track "tangible results" such as improved beneficiary outcomes. For example, how many babies born to Medicaid are "thriving" due to program innovations.

As for Medicaid's integrity, Verma stressed that states and the federal government would need to work together to end fraud, waste, and abuse.

Finally, alluding to the block grant framework included in many Republican ACA repeal-and-replace efforts, she said she would continue to champion changes to Medicaid laws.

Verma acknowledged the partisan divide of the last several months, and called for teamwork. "While we may debate about how Medicaid should be structured, and how to apply resources, the simple fact remains that we are on the same team. We are Americans working together to help Americans in need."

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